Permit ,
1,
n CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00189
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 8/16/2007
PARCEL: 1 S135BD - 00100
SITE ADDRESS: 09600 SW OAK ST 350 ZONING: C -P
SUBDIVISION: PLAZA WEST LOT: 005 JURISDICTION: TIG
PROJECT: SLEEP WELL PARTNERS
Project Description: .3 EDU increase.
TENANT NAME: SLEEP WELL PARTNERS
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.3
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
ASA PROPERTIES, INC
BY PAUL DEVILLE Description Date Amount
PO BOX 3110
HONOLULU, HI 96802 [SWUSA] Sewer Connection Fee 8/16/2007 $840.00
Phone: Total $840.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through
OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued by: Permittee Signature: '9 Qom
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 1S135BD -00100
Tenant Name: SleelrWell Partners This SWR# SWR2007 - 00189
Site Address: 9600 SW Oak St. Tigard, OR 97223 This PLM# PLM2007 - 00335
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 • 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
-3inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) - 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 1 -HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 2 4 2 4
Sink - Bar /Lavatory 2 1 2 0 0 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 • 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0-
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 1 6 0 0 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TO'l'AI.S 2 8 . 0 0 2 4 4 12
Current Fixture Value 12 divided by 16 = 0.8 Current EDU 1 EDU = $ 2,800
Previous Fixture Value 8 divided by 16 = 0.5 Previous EDU
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Change 4 divided by 16 = 0.3 over (under) 5 840.00
Enter EDU Change Here 0.3
Notes: .
Authorized Name /Signature: Savanna Newell Date: 7/27/2007
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges. • I: \Building \ Forms \Scwerl'allyShcct.xls 02 /02/07 /
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